Criteria
Cardiac rehabilitation programs, Phase II Outpatient may be considered medically necessary when individually prescribed by a physician and the following criteria are met:
- Initiated within 12 months of ANY of the following:
- Acute myocardial infarction (MI) (heart attack); or
- Coronary artery bypass graft (CABG) surgery); or
- Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; or
- Heart valve surgery; or
- Heart or heart-lung transplantation; or
- Current stable angina pectoris; or
- Compensated heart failure; or
- Coronary artery disease (CAD) associated with chronic; stable angina pectoris that has failed to respond adequately to pharmacotherapy and is interfering with the ability to perform age-related activities of daily living and/or impairing functional abilities; and
- The individual does not have an absolute contraindication to cardiac rehabilitation (examples include: unstable angina, overt cardiac failure, dangerous arrhythmias, dissecting aneurysm, myocarditis, acute pericarditis, severe obstruction of the left ventricular outflow tract, severe hypertension, exertional hypotension or syncope, uncontrolled diabetes mellitus, severe orthopedic limitations, and recent systemic or pulmonary embolus).
Following the initial evaluation, services provided in conjunction with a phase II outpatient cardiac rehab program may be considered medically necessary for up to 36 sessions, three (3) sessions per week, for a 12-week period. The need for supervised exercise sessions can be determined by the individual's risk stratification as follows:
- Low Risk: six (6)-18 exercise sessions
- Moderate Risk: 12-24 exercise sessions
- High Risk: 18-36 exercise sessions
A routine cardiac rehabilitation session usually consists of an exercise training session lasting 20-60 minutes and at least ONE of the following services:
- Continuous ECG/EKG monitoring during exercise; or
- EKG rhythm strip with interpretation and physician's revision of the exercise program; and/or
- Limited physician follow-up to adjust medication or other treatment(s) related to the program.
Cardiac rehabilitation exercise programs beyond the initial 12-week/36 session will require individual medical review. If documentation substantiates that additional sessions are medically necessary to reach a realistic and achievable increase in work capacity, the number of services may be extended, but not exceed a maximum of 24 weeks or 72 sessions.
Phase II cardiac rehabilitation services that do not meet the medical necessity criteria and frequency guidelines outlined in this policy will be denied as not medically necessary.
Maintenance exercise programs undertaken by the participant after formal freestanding clinic or facility based programs are completed, are not covered.
Generally, psychotherapy and psychological testing are not considered medically necessary for all cardiac rehabilitation participants. However, if a participant has been diagnosed with a mental, psychoneurotic or personality disorder, psychotherapy performed by a psychiatrist or a psychologist may be considered medically necessary. In addition, psychological diagnostic testing of a cardiac rehabilitation participant who exhibits symptoms of mental illness or mental problems (e.g., anxiety disorder associated with the cardiac disease) may be considered medically necessary.
Physical and/or occupational therapies are considered not medically necessary in conjunction with cardiac rehabilitation services unless performed for an unrelated diagnosis (e.g., a participant who is recuperating from an acute phase of heart disease may have also had a stroke which could require physical and/or occupational therapies).
Repeat participation in an outpatient cardiac rehabilitation program in the absence of another qualifying cardiac event is considered experimental/investigational and therefore, non-covered. Scientific evidence does not support the need for repeat cardiac rehabilitation in the absence of cardiac events.
Educational services (e.g., lectures, counseling) that may be provided as part of a cardiac rehabilitation exercise program are not eligible for separate reimbursement.
Phase III cardiac rehabilitation programs, or self-directed, self-controlled or monitored exercise programs are considered not medically necessary.
Phase IV cardiac rehabilitation programs or maintenance therapy that may be safely carried out without medical supervision are considered not medically necessary
Cardiac rehabilitation when used in a preventive or prophylactic way, such as for angina, hypertension, or diabetes is considered not medically necessary.
